Application to Suspend an Environmental Authority

Application form

Application to suspend an environmental authority

Environmental Protection Act 1994

Application to suspend an environmental authority

This document is the approved form required under section 284B of the Environmental Protection Act 1994 (EPAct) for the holder of an environmental authority to request a suspension of that environmental authority.

This application form can be used by the holder of an environmental authority to temporarily suspend the environmental authority. This means that the operation of all environmentally relevant activities (ERAs) approved under the environmental authority must cease during the suspension period. Annual fees will not be payable during the suspension period.

If you would like to have a pre-lodgement meeting:

• for prescribed ERAs 2, 3 and 4—contact the Department of Agriculture and Fisheries by email at .
• for any other ERA—please fill out and lodge the form Application for a Pre-Design/Pre-Lodgement Meeting (ESR/2015/1664[1]), prior to lodging this application form.

Checklist for making this application

You must complete this checklist in order to continue.

If you have answered yes to the below question, you cannot use this application form. If you have answered ‘no’ to the below question, you may continue to use this application form.

Checklist question / Guidance
Are there conditions of the environmental authority that require rehabilitation? / YES
NO / If yes, the administering authority cannot approve the application.
GUIDE /

Application details

If you require assistance in answering any part of this form, or have any questions about your application please contact the relevant department. Contact details are at the end of this form
The environmental authoritynumber and details may be found on the existing environmental authority or quoted in other correspondence received from the administering authority.
If more space is required for any responses, please attach additional information as a separate page.
If there is an agent acting on behalf of the environmental authority holder, provide details in this section. An agent could be a consultant or a contact for the environmental authority holder.
As statutory documents need to be sent to all applicants, this section can also be used when there are multiple environmental authority holders to nominate an address for statutory documentation to be sent ‘care of’ to. /

1.Environmental authoritynumber

ENVIRONMENTAL AUTHORITY NUMBER
ENVIRONMENTAL AUTHORITY HOLDER NAMES
Agent details/address for service
The address supplied here will also be used as a service address for sending statutory documents. If this section is left blank, statutory documents will be sent to the address previously supplied for the holder or principal applicant for the environmental authority.
INDIVIDUAL OR BUSINESS NAME (INCLUDE TRADING NAME IF RELEVANT)
RESIDENTIAL ADDRESS OR REGISTERED BUSINESS ADDRESS (NOT A POST OFFICE BOX ADDRESS)
CONTACT PERSON
PHONE / FACSIMILE
EMAIL
Describe the reasons for the suspension. Include any relevant events that have led up to this application e.g. hazardous spills. Also describe any activities that will be occurring on site during the suspension period. /

2.Describe the reason for the suspension

REASON FOR THE SUSPENSION
Only a person with appropriate environmental expertise and/or experience in planning and executing site operations should sign this compliance statement. This person may be the environmental authority holder, a full-time employee of the environmental authority holder or a consultant to the environmental authority holder.
Methods to verify compliance may include a desktop assessment of documentation, an interview with the landowner/holder or a field operator or a site inspection. Evidence used may include photographs, statements and other documentation (maps, plans, approvals, monitoring results etc). /

3.Compliance statement

This compliance statement must be completed by, or on behalf of the environmental authority holder.
Attach a separate document to this application form which states the extent to which the activities carried out under the environmental authority have complied with each condition of approval
Describe the qualifications and experience of the person signing the compliance statement.
Provide details of the date, method and evidence used to verify compliance and accuracy.
Provide the contact number of the person signing the compliance statement
I ...... ,
(insert name and position of person making the compliance statement)

• Make the compliance statement by or for the holder of the environmental authority.
• Confirm that, to the best of my knowledge, all information provided as part of this compliance statement, including attachments, is true, correct and complete. I am aware that it is an offence under section 480 of the Environmental Protection Act 1994, to give the administering authority information that I know is false, misleading or incomplete.
• Confirm that, to the best of my knowledge, this compliance statement, including attachments, does not include false, misleading or incomplete information.
• Confirm that, to the best of my knowledge, I have not knowingly failed to reveal any relevant information or document to the administering authority.
• Confirm that, to the best of my knowledge, all information provided in this compliance statement, including attachments, address the relevant matters and are factually correct.
• Confirm that the opinions expressed in this compliance statement, including attachments, are honestly and reasonably held.
• I understand that all information supplied as part of this compliance statement, including attachments, can be disclosed publicly in accordance with the Right to Information Act 2009 and the Evidence Act 1977.

SIGNATURE
DATE
The information provided here, will assist the administering authority to determine:

• The risk of environmental harm occurring during the suspension period.
• The likelihood of action being required to rehabilitate or restore and protect the environment because of environmental harm being caused during the suspension period.

/

4.Environmental impact

Provide the following detail:

An assessment of whether environmental harm will occur, or has the potential to occur, during the suspension period.

A description of management/mitigation measures that will be implemented to manage any environmental risk during the suspension period. Include timeframes for implementing the management/mitigation measures.

DETAILS
The proposed suspension period must be for 1-3 whole years from the next anniversary day for the environmental authority.
To terminate the suspension either before the suspension takes effect or during the suspension period, written notification must be given to the administering authority, accompanied by the proportion of the annual fee for the period when the suspension terminates to the next anniversary day (see section 140A of the Environmental Protection Regulation 2008). Forexample, where the suspension is terminated 73 days before the next anniversary day one-fifth of the annual fee is payable (73 divided by 365 gives 0.2 which is 20% or one fifth). /

5.Nominate the proposed suspension period

START DATE (NEXT ANNIVERSARY DAY) / END DATE (ANNIVERSARY DAY
Note: The suspension period cannot commence before the next anniversary day, and must be for a period ofone,two orthreewhole years. For example if this application is made in April 2013 and the next anniversary day for the environmental authority is 18June2013, the suspension period must start on 18 June 2013,finish on 18 June 2014, 18 June 2015 or 18June 2016.
You must not commence or continue the operation of any activities approved under the environmental authority until the suspension period ends and financial assurance is given (if required).
Annual fees will become payable once the suspension period ends.
Where there is more than 1 holder of the environmental authority, this declaration is to be signed by all holders, unless there is an agreement between all holders that 1 can sign on behalf of the other.
Note: If only one holder is signing this application form, they are committing all holders to the content of the application and the declaration.
Where the environmental authority holder is a company, this formmust be signed by an authorised person for that company.
Privacy statement
The Departments of Environment and Science (DES) and Agriculture and Fisheries (DAF) are collecting the information on this form to process your application to suspend an environmental authority. This collection is authorised under sections 284A and 284B of the Environmental Protection Act 1994. Some information may be given to the Department of Natural Resources Mines and Energy (DNRME) for the purposes of processing this application. Your personal information will only be accessed by authorised employees within these departments and will not be disclosed to any other parties unless authorised or required by law. For queries about privacy matters please email or telephone: 137468. /

6.Declaration

Note: If you have not told the truth in this application you may be prosecuted.
Where an agreement is in place between all holders of the environmental authority that one holder can sign on behalf of the other joint holders, please tick the below checkbox.
I have the authority to sign this form on behalf of all the joint holders of the environmental authority.
I declare that:

• I am the holder of the environmental authority or an authorised signatory for the environmental authority holder.
• The information provided is true and correct to the best of my knowledge. I understand that it is an offence under section 480 of the Environmental Protection Act 1994 to give to the administering authority or an authorised person a document containing information that I know is false, misleading or incomplete in a material particular.
• I understand that failure to provide sufficient information may result in the application being refused.
• I understand that all information supplied on or with this application form may be disclosed publicly in accordance with the Right to Information Act 2009 and the Evidence Act 1977.

ENVIRONMENTAL AUTHORITY HOLDER’S NAME
SIGNATURE
POSITION OF SIGNATORY / DATE
JOINT HOLDER’S NAME (IF APPLICABLE) / JOINT HOLDER’S SIGNATURE (IF APPLICABLE)
JOINT HOLDER’S NAME (IF APPLICABLE) / JOINT HOLDER’S SIGNATURE (IF APPLICABLE)
Applicant checklist
Application form has been signed and all questions completed.
Supporting information attached (if applicable)

Fees paid or enclosed

Further information
The latest version of this publication and other publications referenced in this document can be found at using the relevant publication number (ESR/2015/1728 for this document) as a search term. /

Please return your completed application kit to

For ERA 2, ERA 3 or ERA 4
Post:
Senior Environmental Scientist
Animal Industries
Department of Agriculture and Fisheries
PO Box 102
TOOWOOMBA QLD 4350 / Enquiries:
Phone:(07) 4688 1374
Fax: (07) 45294192
Email:
For all other ERAs
Post:
Department of Environment and Science
GPO Box 2454
BRISBANE QLD 4001 / Courier or hand delivery:
Permit and Licence Management
Department of Environment and Science
Level 3, 400 George Street
BRISBANE QLD 4000
Business hours: 8:30am–4:30pm business days
Enquiries:
Permit and Licence Management
Phone: 13 QGOV (13 74 68)
Fax: (07) 3330 5875
Email:

Page 1 of 7 • ESR/2015/1728• Version 4.03• Effective: 21 NOV 2014Department of Environment and Science

[1] This is the publication number. The publication number can be used as a search term to find the latest version of a publication at .